ElderGrade

Inspection citations at Evan Terrace Post Acute

58 citations on record, 2 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2026 1 0
2025 22 1
2024 17 0
2023 18 1
D March 16, 2026 Tag F0690 Complaint investigation Corrected Mar 2026

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

No actual harm, potential for more than minimal harm

D November 18, 2025 Tag F0693 Complaint investigation Corrected Nov 2025

Quality of Life and Care Deficiencies

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

No actual harm, potential for more than minimal harm

D June 16, 2025 Tag F0940 Complaint investigation Corrected Jul 2025

Administration Deficiencies

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

No actual harm, potential for more than minimal harm

E June 16, 2025 Tag F0684 Complaint investigation Corrected Jul 2025

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

G June 16, 2025 Tag F0686 Complaint investigation Corrected Jul 2025

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Actual harm to a resident

C June 9, 2025 Tag F0732 Corrected Jul 2025

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

No actual harm, minimal potential

C June 9, 2025 Tag F0577 Corrected Jul 2025

Resident Rights Deficiencies

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

No actual harm, minimal potential

D June 9, 2025 Tag F0842 Corrected Jul 2025

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

No actual harm, potential for more than minimal harm

D June 9, 2025 Tag F0825 Corrected Jul 2025

Quality of Life and Care Deficiencies

Provide or get specialized rehabilitative services as required for a resident.

No actual harm, potential for more than minimal harm

D June 9, 2025 Tag F0744 Corrected Jul 2025

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

No actual harm, potential for more than minimal harm

D June 9, 2025 Tag F0693 Corrected Jul 2025

Quality of Life and Care Deficiencies

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

No actual harm, potential for more than minimal harm

D June 9, 2025 Tag F0689 Complaint investigation Corrected Jul 2025

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D June 9, 2025 Tag F0684 Corrected Jul 2025

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D June 9, 2025 Tag F0656 Corrected Jul 2025

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

D June 9, 2025 Tag F0605 Corrected Jul 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

No actual harm, potential for more than minimal harm

D June 9, 2025 Tag F0561 Corrected Jul 2025

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

No actual harm, potential for more than minimal harm

D June 9, 2025 Tag F0552 Corrected Jul 2025

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

No actual harm, potential for more than minimal harm

E June 9, 2025 Tag F0880 Corrected Jul 2025

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

E June 9, 2025 Tag F0756 Corrected Jul 2025

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

No actual harm, potential for more than minimal harm

E June 9, 2025 Tag F0610 Complaint investigation Corrected Jul 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

No actual harm, potential for more than minimal harm

E June 9, 2025 Tag F0609 Complaint investigation Corrected Jul 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, potential for more than minimal harm

D March 4, 2025 Tag F0825 Complaint investigation Corrected Apr 2025

Quality of Life and Care Deficiencies

Provide or get specialized rehabilitative services as required for a resident.

No actual harm, potential for more than minimal harm

D March 4, 2025 Tag F0684 Complaint investigation Corrected Apr 2025

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D November 26, 2024 Tag F0760 Complaint investigation Corrected Jan 2025

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

No actual harm, potential for more than minimal harm

D November 26, 2024 Tag F0693 Complaint investigation Corrected Jan 2025

Quality of Life and Care Deficiencies

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

No actual harm, potential for more than minimal harm

D November 26, 2024 Tag F0684 Complaint investigation Corrected Jan 2025

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D November 26, 2024 Tag F0660 Complaint investigation Corrected Jan 2025

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

No actual harm, potential for more than minimal harm

D November 26, 2024 Tag F0655 Complaint investigation Corrected Jan 2025

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

No actual harm, potential for more than minimal harm

D November 26, 2024 Tag F0610 Complaint investigation Corrected Jan 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

No actual harm, potential for more than minimal harm

E November 26, 2024 Tag F0726 Complaint investigation Corrected Jan 2025

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

No actual harm, potential for more than minimal harm

F November 26, 2024 Tag F0838 Complaint investigation Corrected Jan 2025

Administration Deficiencies

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

No actual harm, potential for more than minimal harm

D April 19, 2024 Tag F0842 Complaint investigation Corrected May 2024

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

No actual harm, potential for more than minimal harm

D April 19, 2024 Tag F0686 Complaint investigation Corrected May 2024

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

No actual harm, potential for more than minimal harm

D April 19, 2024 Tag F0657 Complaint investigation Corrected May 2024

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

No actual harm, potential for more than minimal harm

D April 19, 2024 Tag F0655 Complaint investigation Corrected May 2024

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

No actual harm, potential for more than minimal harm

D April 19, 2024 Tag F0641 Complaint investigation Corrected May 2024

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

No actual harm, potential for more than minimal harm

E April 19, 2024 Tag F0761 Complaint investigation Corrected May 2024

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

No actual harm, potential for more than minimal harm

E April 19, 2024 Tag F0757 Complaint investigation Corrected May 2024

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

No actual harm, potential for more than minimal harm

E April 19, 2024 Tag F0725 Complaint investigation Corrected May 2024

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

No actual harm, potential for more than minimal harm

E April 19, 2024 Tag F0684 Complaint investigation Corrected May 2024

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.